Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Wednesday, September 06, 2006

In the natural world it's easy to tell the predators from the prey. The predators have claws, talons, sharp incisors and stereoscopic vision. The prey tend to breed like telemarketers and travel in packs. They use camouflage to look like inanimate objects or distasteful creatures. Humans have adapted some defensive techniques from the natural world in rather ingenious ways. During World War II (what is it with me and history, anyway?) maritime traders discovered that more of their cargo made it past German U-boats if they travelled in fleets or convoys rather than individually with armed escorts. My personal favorite adaptation was by a runner who painted large owl-like eyespots on the top of his cap to keep the starlings from dive-bombing him. (I wonder if if dive-bombing birds are a problem for rock climbers...er, boulderers. I guess you could throw ropes at them. If you used ropes.)

To bring this back to relevance, in the correctional world I have trouble telling the difference between predators and prey. There are times when it seems to me that a lot of the teardrop tattoos, gang symbols and gold teeth are mainly defensive adaptations to keep away the predators. I've also been told by some prisoners that they purposely cultivate a 'crazy' unpredictable persona to keep from being victimized. One correctional psychologist told me about an inmate who hated being touched so much that he purposely smeared feces over his body to keep the officers' hands off him when he came out of his cell (to shower, I hope). Meanwhile, I'm ironically working with my seriously mentally ill patients to try to help them 'blend in' to general population and seem as normal as possible.

The more concerning thing is predator recognition, both for personal safety (see previous blog post Risky Business) and for the safety of my patients. Sometimes inmates come for mental health care specifically because of victimization issues that they may or may not be willing to tell you about. They may tell a false or misleading chief complaint specifically to get moved off a tier or to get hospitalized away from the predator. Predators also have been known to 'scam' their way on to a unit specifically to get close to someone they're 'leaning' on. And you have no clue this is going on unless a tier officer knows his or her unit well enough to fill you in on the history. Repeated psychiatric hospitalizations are sometimes a clue that the tier has become an unfriendly place for prison-prey. It all boils down to experience, the ability to piece together knowledge about specific units and inmates, and familiarity with enough prison scenarios to read between the lines.

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And now for something completely different. Well, not completely different. In fact, it's actually somewhat relevant for a change.

According to the Occupational Safety and Health Administration, the average annual rate of non-fatal violent crime is 16.2 per 1,000 workers for physicians, 21.9 for nurses and 68.2 for mental health professionals. (And no, I don't know how they classified physicians who are mental health professionals.) OSHA identifies a number of risk factors for workplace violence in healthcare settings: the presence of forensic patients (that's my euphemism for OSHA's reference to 'criminal...acutely disturbed violent individuals'), increased numbers of mentally ill patients (yeah yeah even the Federal government blames those 'dangerous nut cases'...sheesh), but most importantly the presence of available drugs or money (back to the nature analogy---it's not good to resemble food). Remote or isolated workplaces with unrestricted pedestrian traffic are also a risk factor. OSHA provides a list of engineering controls (apparently their term of art for physical modifications) to prevent violence (see OSHA link). Personally I think there's no substitute for a large human presence with a soft voice and laid back temperament. And forget the personal alarms and buzzers---just scream.

After thinking about this post, I ending up feeling like Pontius Pilate:"What is truth?" My further comment would be an essay, so I will respond at home (and credit where due). I have to stop reading these ShrinkRappers. I am over-stimulated...

The details of the defendant's insanity defense won't be known for over a year when the case finally goes to trial, if he decides to go forward with the defense after the evaluations are done. In the meantime whatever is known may get reported in the local newspaper here or better yet in the Washington Post. And if by weird coincidence any reader knows anything beyond what gets reported in the media they would do well not to post it on a blog unless they want to get subpoenaed to testify in a murder trial. These things happen.

I've just started writing a book with two other psychiatirsts (not by blogmates) on errors to avoid in psychiatry (like prescribing lithium and HCTZ, or mistaking alcohol-induced depression for major depression).

I've also had a hard time starting... in part because I've had no time... it's also that blank page thing.

If you have any suggestions or doozies, let me know. I'll name one of my Patient X characters after you.